Strengthening Effectiveness and Efficiency in PEPFAR Programs By Improving Analysis of Expenditures


by Ambassador Eric Goosby, M.D., U.S. Global AIDS Coordinator

Over the last decade, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has proven that it is possible to overcome resource limitations and health systems barriers to deliver HIV prevention, treatment, and care to areas around the world hardest hit by the AIDS epidemic. To date, PEPFAR has supported over 5.1 million people with lifesaving treatment, has prevented millions from becoming infected with HIV, and as of last month, it reached one of its greatest milestones yet—the birth of the one millionth baby to be born HIV-free. However, despite these accomplishments more work needs to be done to address unmet needs and save even more lives.

Today’s global economic climate has forced all partners in the global AIDS response to do more with reduced or finite resources. As stated in the PEPFAR Blueprint for an AIDS-free Generation, improved collection and use of economic and financial data is critical to increasing the efficiency, effectiveness, and sustainability of programs. In 2009, PEPFAR began to pilot the Expenditure Analysis Initiative, tracking expenditures for PEPFAR programs to provide rigorous financial monitoring. This analysis provides detailed annual data on expenditures by program area, cost category, and region. Better access to updated economic and financial data and indicators will allow for PEPFAR programmers and national governments to make rapid course corrections if needed to improve planning and effectiveness, and maximize efficiency in the use of resources.

Specifically, expenditure analysis is designed to:

• Provide a better understanding of the expenses the U.S. government incurs to provide a range of HIV services in the countries in which it works;

• Highlight the areas for improved efficiency and improve alignment of future investments to program needs;

• Estimate the resources needed to support programs in the future; and

• Better understand unit expenditures by program area and service provider.

From 2009 to 2012, PEPFAR piloted expenditure analysis in eight countries: the Democratic Republic of Congo, Guyana, Mozambique, Nigeria, South Africa, Uganda, Vietnam, and Zambia. In each country, the expenditure analysis exercise provided valuable insight on the methods to conduct a rapid assessment of expenditures and link those expenditures to program results. In South Africa, the analysis resulted in a detailed look at how PEPFAR support was distributed across program areas in selected provinces, which informed concrete budget decisions and plans for the transition of greater program responsibility to the Government of South Africa. In Mozambique, the first country in which expenditure analysis was conducted, the data showed that even with a doubling of the number of people in facility-based care and treatment, the average PEPFAR expenditure per patient-year declined by 45 percent. In addition, the variation of the unit expenditure among the five PEPFAR-supported care and treatment implementing partners narrowed.

The Expenditure Analysis Initiative, currently being rolled out PEPFAR-wide, illustrates how the information collected will help direct our programs to stretch each dollar further through smart investments. PEPFAR’s contribution, however, is only one piece of the puzzle. To truly maximize program impact and find additional efficiencies, we need to work with partner governments as well as with multilateral and bilateral organizations to generate a complete picture of all resources currently supporting national AIDS responses. To this end, PEPFAR is actively engaged with the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank, UNAIDS, and other partners on harmonizing expenditure categories across donor and national accounting systems. This will help partner countries to have a more comprehensive picture of existing AIDS resources and position them to eliminate duplications.

As the global community unites to use all of the information at hand, more lives will be saved and the world will be closer to achieving an AIDS-free generation.

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